…I’ve moved abroad in a pandemic just before Brexit and need to sort out various health-related matters. What are my chances?
[Doctor just starts laughing]
I may have mentioned once that I wasn’t going to write anything about the French health system, because it was going to be very dull. But now I’ve more-or-less got a hold on it and have pretty much sorted out all the admin related to it, it seems worth saying a bit about it. So, don’t say you weren’t warned if you fall asleep reading this one[1].
Right, the French health system. It’s big, complicated and quite different from the NHS in many ways. Certainly, if you’ve grown up in Britain, it feels as if it involves a lot more effort at your end. But, let’s start with the basics: the French system is insurance-based. Everyone pays social security contributions out of their salary, in the same way as people pay NI in the UK. But, unlike in the UK, this doesn’t entitle you to free care in the state system. What it does entitle you to is the basic state insurance scheme, which will cover something like two-thirds of most of your health expenses. This sounds OK, until you look at the actual costs of things and realise that paying one third of the costs for every trip to the GP, hospital and so on, can leave you quite out-of-pocket quite quickly. Actually, you may be paying a bit more than one-third, because what the state scheme actually covers is two-thirds of the state rate for healthcare expenses. Healthcare providers, however, are allowed to set their own rates for care, which may well exceed the state rates[2], so you can be left with quite a shortfall if you’re relying purely on the basic insurance.
To avoid falling into this potential hole, you can buy additional healthcare insurance – this may well be provided by your employer, or you can look on the private market – that will cover some of the shortfall some of the time. Depending on what additional insurance you opt for, you may well be covered for expenses over 100% of the state rate on some things[3]; obviously, the more your additional insurance covers, the more expensive it’ll be. Suffice to say that you’ll be able to find something that suits your needs, though it won’t necessarily be all that cheap – you could well be spending 50-100 euros a month.
So, you’ve got your insurance. Now you have to claim on this if you actually need to go to the doctor or anything. This used to be done by filling in lots of forms; nowadays, you get what’s called a carte vitale, which is just a smartcard that has all the relevant information stored on it. You just hand it over when you need to pay for anything, it gets scanned, and everything sorts itself out. Once you’ve got one. As an expat, though, this takes B L O O D Y A G E S. So I’ve spent a lot of time messing around with forms, both to claim back health expenses and to avoid having to fill in more forms in the future. First of all, you have to go and get signed up with your basic state insurance – your employer doesn’t do it for you, unlike in the UK – which involves making an appointment. Three weeks or so after that, you’ll hear from the social-security people. Then you have to send them stuff[4] and, a few weeks/months/years later, you’ll be signed up with a social-security number and get the paperwork through to apply for your carte vitale. Which obviously then takes a while to process. So, with a bit of luck, I might just get one before my initial contract runs out. Say what you want about the NHS: the fact that the only real criterion for treatment is to reside in the UK and that you can just turn up and get free care at any doctor or hospital is great.
Anyway, you’ve done all the set-up: now you have to go and get some treatment for your whatever’s-wrong-with-you[5]. The first thing to say is that there are loads of doctors in France. Within 200 m of my front door, there are about ten registered. The difference with the UK is that they often only work in individual or small-group practices, rather than big surgeries, so it’s a less-centralised model. What this also means is that a French doctor is unlikely to offer the range of services you get at most GPs in the UK: for most routine medical interventions – blood tests say – you have to go to a medical laboratory with a prescription from your GP, who will then get sent the results and call you back. This means that medical matters can be a lot more drawn out than in the UK, where everything is often done on-site in one appointment, though you don’t need an appointment to head to the lab in France, at least. But it still involves having to go somewhere else and therefore takes a while, even if there isn’t a queue or anything. Because these labs are also where you go to have covid tests, so they’re pretty popular right now, as I found out when I went for my blood test as part of my initial general check-up. Similarly, you’ll have to go to a separate pharmacy to pick up any medicine. It’s also worth noting that pharmacies are the only place you can buy drugs of any kind in France, which is really annoying if all you want is generic paracetamol or ibuprofen or similar, because the pharmacy will only sell you expensive branded versions[6].
This general disconnectedness becomes a bit more of a problem in, say, a hospital, because what your doctor will do if you need to be seen by another service, is write you a prescription that you then have to take to the relevant place and organise the appointment for yourself. So, if you need an MRI or similar, you have to get in contact with the radiology department yourself. It’s just a bit messy and means you, the patient, have to do a lot more work, though you do get more control over who you see when. And also ends up with you storing things such as a tetanus booster shot in your fridge. Because your GP doesn’t have it on hand (obviously), so it’s to the pharmacy with a prescription and you keeping hold of it until your next appointment. I suppose I get more control, again, over my medication, but I can’t see that letting private individuals keep real medical-grade stuff at home for extended periods working out well in the grand scheme of things. Kids, pets, idiocy, are all real hazards that you’re unnecessarily amplifying this way….
Another relevant point is which doctor do you choose? You can find all kinds, but you’re usually going to want to go to a médecin généraliste first – in other words, a GP – because what you have to do in France is declare a médecin traitant. This is effectively ‘your’ doctor that is responsible for looking after you and is your first point of call. The reason this is important is because, if you need more specialist care, your médecin traitant is the one that’s supposed to refer you. You can not do this, but then your insurance won’t cover as much of the costs[7]. You can declare specialist doctors as your médecin traitant if you wish, but, obviously, picking a GP is a pretty good bet unless you’re certain you’re only going to need one kind of doctor. There’s also more GPs, so you can probably find one pretty much on your doorstep – mine is 120 m away. Though you can pick one anywhere in the country, if, for some reason, you want to travel for your appointments[8].
Anyway, you’ve got all your insurance set up, you’ve chosen a doctor, you’ve had an appointment and you’ve picked up your medicine. Wasn’t too hard, was it? Well, not by comparison with, say, walking up Mont Blanc in a kangaroo onesie whilst continuously playing the Marseillaise on the bagpipes. In the fog. Backwards.
Now, to finish, you might be thinking that an obvious flaw with the system is: what happens if you’ve got some sort of pre-existing chronic condition that means you need a regular, possibly quite expensive, prescription? Surely no private insurer is going to cover that, leaving you with just the basic state rate and hundreds of euros out of pocket every month? Well, fortunately, this is the Socialist Workers’ Paradise of the French Republic, not the US, so the government has actually thought about this. If you have one of the government-approved chronic conditions[9], the state scheme will cover 100% of your healthcare expenses for appointments, drugs, etc. related to that condition. And the private insurers aren’t allowed to discriminate against you anyway. And you will still want the additional private insurance, because the government won’t foot the bill for your other medical expenses – say, if you’ve got cancer, you fall down the steps and break your leg because you’re a clumsy bugger, you’ll be back on the usual government rate for treatment for the leg.
And, finally finally, the other problem is, of course, cost. Much like the NHS and basically every Western state healthcare/social-security system, the French system is a black hole of money. The population’s ageing, so health costs are going up, but at the same time the working-age proportion of the population is shrinking, so tax receipts and therefore funding is going down. Though the French are doing marginally better on this demographic decline than much of Europe. So, much as in the UK, it’s likely to get less generous at some point….
[1] This is how you manage expectations.
[2] Whether this is the case is something you know in advance. Healthcare providers in France can be ‘Secteur 1’, which means they will only charge the state rates at most for anything, or ‘Secteur 2’, which means they’ll charge more, and this is advertised on ameli.fr, the French national website for searching for healthcare providers and all things healthcare. You can pretty much assimilate this difference to the NHS/private-sector healthcare divide in the UK. A Secteur 2 doctor will cost you (or your insurance) more, but you’ll probably get seen quicker than if you stay in Secteur 1.
[3] This is particularly useful if you plan on going to dentists or ophthalmologists (unlike in the UK, opticians in France are purely people who sell glasses; you have to go to an actual ophthalmological doctor to get your eyes tested) – the French government, a few years back, had to mandate maximum rates for these sectors, because no one was going to have their eyes or teeth checked, because the practitioners were charging stupid rates.
[4] I ended up spending 100 quid on sending my birth certificate back to the UK to get an apostille – a fancy stamp – put on it to prove it was real, and on getting it officially translated into French, a job I could have done in five minutes. Which took two weeks on its own; if someone had told me I’d need to do this at the start, rather than only once I was trying to get on social security, I could have saved a lot of time.
[5] I fully realise that phrasing it like that makes it sound as if it’s a euphemism for some sort of STI or other delicate condition.
[6] What you do get in the supermarkets is all sorts of what the French call médecine doux, which is what we’d call complementary therapies or, if you’re feeling uncharitable, ineffective quackery. The French love all this stuff – phytotherapy, homeopathy, osteopathy, acupuncture – to the extent that I was recommended an osteopathy session by my health insurer. Now, some of it has some effect, but some of it doesn’t and, given the choice, I’d rather stick with actual drugs, please.
[7] This is what’s called the parcours de soins coordonnés in France. You’re ill, you go to your declared médecin traitant, who refers you up the chain as required. You’re happy, your insurance is happy and everyone wins. It might just take a while.
[8] Or, I suppose, if you’ve got something very niche wrong with you that only one doctor knows about. Unfortunately for you, he lives on a barren windswept rock off the Atlantic coast only reachable by ferry every third day if it’s not a weekend, public holiday, wet, windy, foggy, and the ferryman’s remembered/bothered to turn up. Because your doctor is actually…A MAD SCIENTIST!!!! This footnote brought to you by the Dali Foundation for Surrealism and Giving Harmonica Lessons To Giraffes.
[9] This is in no way a restrictive list, don’t worry.